MCCQE 1 Preparation

1. MCCQE 1 Preparation Paediatric Orthopaedics Dr. Ken Kontio

2. Outline • Exam content mainly • Common / bread n`butter topics • Meat and potatoes • Questions?

3. Case • 7 month old presenting with leg concern • Mother noticed left leg shorter to finger assisted standing • Exam shows Ortilani/Barlow tests neg, mildly decreased Abduction left hip, mild LLD with left shorter than right • What do you think is going on?

4. Options • Xrays legs to find site of shortening • U/S hips to diagnosis possible DDH (dislocation) • Xray hips to confirm dislocation hip • Give shoe lift for better posturing • Pavlik harness for obvious hip dislocation clinically

5. DDH • Commonest paediatric hip problem early on • Presentation may be very benign • Decreased abduction most sensitive after 3-6mo • Exam : Ortolani + for dislocated hip Barlow + for dislocatable hip • Workup U/S early (<3mo) • Ossification femoral epiphysis 3-6 mo • Xray later due to void defect from ossification

6. DDH • Treatment • Dislocated - reduction, confirmation, pavlik • Dislocatable - immediate post birth, repeat later - later, pavlik Pavlik continues until normal U/S or Xray (AI<22º) • Late may need CR (spika) older than 6 mo • Later may need surgery, older than 1 year (painless limp-todler or less) • Long term follow for normal acetabular development (surgery if no AI in 18mo)

7. DDH

8. Case • 6 year old boy with pain in the Rt knee • Limps at end of day, no complaints of pain • Exam shows mild limp, • Knee exam normal • What to Do?

9. Options • Give tensor for sore knee • Xray knee to rule out fracture • Examine hips for source of problem • MRI knee to rule out meniscal pathology • Tap knee for possible infection

10. Perthes • Hip concern in child 4-8 years • Commonly knee pain as presenting complaint • If leg pain always think about hip pathology • Presentation • Painless limp • Decreased ROM (esp. Abd, IR)

11. Perthes

12. Perthes • X-Ray • Unilateral or mixed stage bilateral • Epiphyseal ossification abnormalities • Tx • Maintain ROM • Coverage issues • Self limiting • Head sphericity key to long term outcome

13. SCFE • Most common cause of hip problems in adolescents • Some able (stable) and some not able (unstable) to walk • Obligatory ER hip with flexion • If not teen consider outliers (endocrine disorders, renal disease) • Xray needed to make diagnosis

14. SCFE • Workup • Xrays show slipped neck-head interface • Tx • All need protection • All need treatment • Pin(s) across slip • Closure about 6-12 months • Watch for avn

15. Scoliosis • Congenital types need progress documented to prove progressive nature • Rule our renal (U/S) or cardiac (Echo) involvement • Infantile AIS, more boys, left convex thoracic curves • Many resolve on their own

16. Scoliosis • Juvinile and adolescent curves • Right thoracic and left lumbar curve directions • Risk of progression 1º maturity related • Presentation • Painless, if painful consider spinal pathology

17. Scoliosis • Treatment • 0-25(30) observe • 25(30)-45(50) brace • 50 or more consider surgery • Brace used until maturity • Surgery to correct and prevent progression

18. Cases • A 6 year old child is brought to your office for assessment of a “longer” leg on one side. • Exam shows that this child has about 1 cm difference, the right longer than the left • Parents wonder if they should be concerned?

19. What would be the expected discrepancy at maturity? • 1cm • 1.5 cm • 2.5 cm • 5cm • 10cm

20. LLD - How would you mange this child? • Tell them that we need to do an operation immediately to shorten the right leg • Tell them that it will stay that way and not be an issue • The child will need a lengthening procedure later in life when done growing • Tell them that it will increase but will be acceptable • Tell them to get a shoe lift when patient complains of pain with walking.

21. LLD • Common presentation • Main issue is LLD at maturity • Most proportional • If 10% less at a certain age, will be same percentage at later age (ie. 10% shorter in 15 cm femur is 1.5 cm, but same child at maturity with 40 cm femur it’s a 4 cm LLD) • Causes include: hemihypertrophy, fibular hemimelia • Half deformity present at 3yrs (girls), 4yrs (boys)

22. LLD • Some are dynamic • Growth arrest after trauma • Will change quickly with time • Growth femur • 20% proximal • 80% distal (9-10 mm/year) • Growth tibia • 40% distal • 60% proxiaml (6 mm/yeal) Example: 10yr old boy (16yrs mature) with distal femur arrest will get (6 yrs growth x 10 mm/yr = 6 cm LLD)

23. General rules: Discrepancy at maturity main concern Length and angulation (both planes) clinically relevant If growing consider using growth arrest If done growing consider lengthening or shortenting 0-2 cm nothing 2-5 cm lift 5-7 cm shortening or lenghtening or epiphysiodesis 7-15 lengthening >15cm amputation and / or prosthetics LLD - Treatment

24. Cases • 4 year old boy presents with pain in his hip and a low grade fever. • Limp started two days earlier • Progressive difficulty walking • Temperature 37.6 (oral), ROM hip irritable • Xray hip normal, WBC mildly increased, ESR up about 35 (0-20) • What is your plan of management?

25. Options • U/S hip, aspiration/ arthrotomy , start antibiotics • Give him NSAID and follow up in 1 week • Start Abx and admit for observation • Start Abx and admit for hip arthrotomy / washout • U/S of hip and start antibiotics • Admit for bone scan and start antibiotics

26. Infection vs Inflammation • Often asked to differentiate between joint involvement (bacterial vs “viral”) • Spectrum of findings • Walking painless limp to bedridden, painful • Workup best to rule out options • Sensitive but not specific • Labs, xrays, physical exam • Radiology • U/S of joints, Bone scans of bones

27. Inflammatory • Presents as benign picture • Little systemic evidence of infection • Recent illness common (URTI) • Tx • Watch for worsening • Workup to rule out other problems • Arrange close follow-up

28. Infective • Active picture clinically • Workup suggestive but not localizing • If joint fluid, obligated to sample • If no fluid, bone scan to rule out osteo • Antibiotic therapy only after samples and treatment (if surgery) carried out • Deep infection needs deep treatment

29. Osteomyelitis • If near joint can mimic septic arthritis (Especially acetabular osteomyelitis) • Pain, fever, minor guarding if at all of joints • Blood cultures, radiographs, then IV Tx before getting bone scan • Weird things such as salmonella common in sickle cell disease, but Staph Aureus still most common in this population

30. Fractures • Salter –Harris classification • II most common • III-IV intra-articular requiring anatomic reduction • V diagnosed after arrest seen

31. Fractures • If displaced and healing • Accept up to 20-30 degrees angulation in plane of joint in young child (<10yrs) • Healing time same, remodelling time about 1 degree /month • If SH injury (I-II) • After 7-10 days do not manipulate for risk of iatrogenic injury to growth plate

32. General Principles • A/B/C • Hx • timing, mechanism, weight-bearing, last meal, allergies • PE • deformity, bleeding, open wounds, bruising, distal pulse, neurological motor and sensory (2-pt discrimination) exam • immobilization • the unstable fracture needs immobilization before imaging (any fracture really) • analgesia • oral/sc/IV

33. General Principles • Investigation • plain film: • 2 views 90 degrees apart including joints above and below • oblique or additional views for certain body parts: • cervical vertebrae, hand, ankle, foot, phalanges • Bone scan • more sensitive in certain settings e.g scaphoid fractures • CT • helps define complex fractures e.g. intra-articular fratures, c-spine fractures (NOT instability) • MRI’s role continues to expand • delineates surrounding tissue injuries e.g. spinal cord compression

34. General Principles • Orthopedic Consultation • general indications • open, unacceptably displaced, neurovascular compromise, significant joint or growth plate involvement • specific indications • non-avulsion pelvic fractures, femur fractures, • dislocation of major joints (not shoulder), spinal fractures

35. Special Considerations • Open fracture • Td, IV Abx, never suture (tightly) overlying skin, ortho consult • Compartment Syndrome • need not be a significant fracture (or no fracture) • pain with passive extension is the earliest sign • Pathologic Fracture • tumors e.g. osteosarcoma • hereditary diseases e.g. osteogenesis imperfecta • metabolic diseases e.g. rickets • neuromuscular diseases e.g. Muscular Dystrophy • infectious diseases e.g. osteomyelitis

36. Case • 9 month old brought in for clicking in thigh and pain with movement of right leg • Mom noticed this 1 hour ago(diaper change) • This morning after baby and twin would not settle down (crying), dad took this (injured) twin to the other room hoping separation would settle things • Dad states he lay with child on bed and baby settled. EXAM: obvious instability mid femur, • Fractured on xray

37. Special Considerations • Child Abuse • features strongly suggestive of abuse • fractures inconsistent with the history • fractures inconsistent with the child’s developmental age • multiple fractures, specially in various stages of healing • fractures in those less than 1 year-old • mid-diaphyseal periosteal elevation • epiphyseal or diaphyseal rib fractures • spiral fractures in non-ambulating children • epiphyseal-metaphyseal fractures: • corner fractures • bucket handle fractures • Skeletal survey required in suspected cases

38. Corner Fractures • 2-month-old female • to ER for decreased movement of the left leg • according to the mother, the infant cries a lot when she is dressed • the step-father told her that while he was cleaning the house, he tripped over the infant's brother and accidentally stepped on the baby

39. Bucket Handle Fracture • 9 m.o. is to ER when it was noted something is wrong with the infant's arm after a toy was pulled away from him • infant was in the care of the baby-sitter at that time.

40. Abuse • Any case you suspect it or think about it as a real possibility, you obligated to contact authorities. • Social worker first line • Abuse team at any children’s hospital • Police if above not available • Document accurately concerns and discrepancies if any…stories change over time.

41. Questions?

42. Remember balance is best!! (Relax and take the time for yourself and family)